Injury acknowledgement by reduction of sports load in world-leading athletics (track and field) athletes varies with their musculoskeletal health literacy and the socioeconomic environment.

OBJECTIVE: Although injury burden prompts elite athletics (track and field) athletes to engage in injury management, little is known about their health literacy. We investigated musculoskeletal (MS) health literacy in world-leading athletics athletes and associations with prechampionship injury acknowledgement by reduction of training load in different socioeconomic environments. METHODS: Adult and youth athletics athletes (n=1785) preparing for World Championships were invited to complete the Literacy in Musculoskeletal Problems instrument and report acknowledgement of injury by reduction in training load during prechampionship tapering. Their socioeconomic standing was estimated through the Human Development Index of their home country. Demographic differences were examined using χ2 tests and determinants of injury acknowledgement assessed using logistic regression. RESULTS: Complete data were obtained from 780 athletes (43.7%) with 26% demonstrating sufficient MS health literacy, higher in adult (41%) than youth (13%) athletes (p<0.001). Adult athletes at the uppermost socioeconomic level showed higher MS health literacy than athletes at lower socioeconomic levels (p<0.001). At the uppermost socioeconomic level, adult athletes with sufficient MS health literacy had increased likelihood of acknowledging an injury by reduction in training load compared with peers demonstrating insufficient MS health literacy (OR=2.45; 95% CI 1.33-4.53). Athletes at middle socioeconomic levels with sufficient MS health literacy had decreased likelihood for acknowledging an injury during tapering (OR=0.29; 95% CI 0.11-0.78). CONCLUSIONS: The prevalence of sufficient MS health literacy in world-leading athletics athletes is low. Associations between MS health literacy and injury acknowledgement in these athletes vary with the resourcefulness of the socioeconomic environment, implying that health literacy and resources for medical and performance support should be ascertained concurrently.

'The Little Engine That Could': A Qualitative Study of Medical Service Access and Effectiveness among Adolescent Athletics Athletes Competing at the Highest International Level.

Little is known about provision of medical services to adolescents prior to participating in international top-level sports. This study aimed to investigate experiences of medical service provision among high-level adolescent athletics (track and field) athletes from three continents. A thematic narrative analysis was applied to data collected from 14 athletes by semi-structured interviews. Although competing at the highest international level, these adolescent athletes had difficulties making sense of symptoms of ill health, especially on their own. With increasing exercise loads, the athletes' medical support needs had extended beyond the capacity of parents and local communities. As there was no organized transfer of the responsibility for medical support to sports organizations, the athletes often had to manage their health problems by themselves. There were major variations among the adolescent athletes with regards to medical service access and quality. The services used ranged from sophisticated computer-assisted biomechanical analyses to traditional healers. Decreased exercise load was the common sports injury treatment. The results of this study demonstrate how the ethical standards underpinning youth sports as well as the equal provision of medical services to adolescents are challenged across the world. Further research on health service provision to adolescent top-level athletes is warranted.

Suicidal thoughts (ideation) among elite athletics (track and field) athletes: associations with sports participation, psychological resourcefulness and having been a victim of sexual and/or physical abuse.

OBJECTIVE: To examine associations between suicidal ideation and sexual and physical abuse among active and recently retired elite athletics (track and field) athletes. METHODS: The study population consisted of all athletes (n=402) selected for a Swedish Athletics team between 2011 and 2017. Data on suicidal ideation, suicidal events (estimated through the 1 year non-sports injury prevalence), lifetime abuse experiences, sociodemographics, sense of coherence and coping strategies were collected using a cross-sectional survey. The data were analysed using binary logistic regression with suicidal ideation and non-sports injury as outcomes. RESULTS: 192 athletes (47.8%) returned data. The prevalence of suicidal ideation was 15.6% (men 17.4%; women 14.2%) and the non-sports injury prevalence was 8.0% (men 11.6%; women 5.7%). Among women, suicidal ideation was associated with having been sexually abused (OR 5.94, 95% CI 1.42 to 24.90; p=0.015) and lower sense of coherence (OR 0.90, 95% CI 0.85 to 0.96; p=0.001) (Nagelkerke R2=0.33). Among men, suicidal ideation was only associated with use of behavioural disengagement for coping (OR 1.51, 95% CI 1.18 to 1.95; p=0.001) (R2 =0.25). Among women, non-sports injury prevalence was associated with having been sexually abused (OR 8.61, 95% CI 1.34 to 55.1; p=0.023) and participating in an endurance event (OR 7.37, 95% CI 1.11 to 48.9; p=0.039 (R2 =0.23), while among men, having immigrant parents (OR 5.67, 95% CI 1.31 to 24.5; p=0.020) (R2 =0.11) was associated with injury outside sports. CONCLUSIONS: About one out of six international athletics athletes reported having experienced suicidal ideation. World Athletics and National Olympic Committees need to include suicide prevention in their athlete protection programmes.

Running for your life: A qualitative study of champion long-distance runners' strategies to sustain excellence in performance and health.

OBJECTIVES: To investigate champion long-distance runners' strategies for managing injury and illness symptoms and staying well. DESIGN: Qualitative research study. METHODS: Twelve long-distance runners were interviewed immediately after having competed in World Championships finals. Thematic analysis was used to categorise and structure the data. The results were presented as primary themes and overarching constructs representing connections between the primary themes. RESULTS: The champion runners' basic tactic to manage symptoms of ill health was characterized by rapid adjustment of sports load and a strong incentive to learn from experience and professional advice. This tactic was named here educated flexibility. A secondary exigency tactic was associated with reaching short-term goals and a consequential acceptance of health hazards. The runners used economic and other environmental strain to explain use of the exigency tactic. Most champion runners' long-term strategy to stay well included both tactics successfully combined to maintain a performance level assuring a regular income. Avoidance of letting environmental strain and health problems create vicious circles was at the centre of these strategies. CONCLUSIONS: Champion runners' main strategy to stay well and sustain their superiority in performance was characterized by constantly paying attention to symptoms of ill health, listening to medical advice, and not letting environmental strain interfere with adjustment of sports load. Many top-level runners originate from global regions where formal education programs and health insurance plans are poorly regulated and supported. Bio-psychosocial models including empowerment at individual and systems levels should be considered when health services are planned for professional runners.

Health complaints and heat stress prevention strategies during taper as predictors of peaked athletic performance at the 2015 World Athletics Championship in hot conditions.

OBJECTIVES: To investigate whether self-reported health complaints and choice of heat stress prevention strategies during the taper predicted peaking at an athletics championship in hot conditions. DESIGN: Cohort study. METHODS: Data on health and heat stress prevention were collected before the 2015 World Athletics Championship in Beijing, China. Peaking was defined using the athlete's pre-competition ranking and final competition rank. Baseline and endpoint data were fitted into multiple logic regression models. RESULTS: Two hundred forty-five (29%) of 841 eligible athletes participated. Both sprint/power (Odds ratio (OR) 0.33 (95% Confidence interval (CI) 0.11 to 0.94), P=0.038) and endurance/combined events (OR 0.38 (95% CI 0.14 to 1.00), P=0.049) athletes having sustained concern-causing health complaints during the taper were less likely to peak. Endurance/combined events athletes who chose pre-cooling to mitigate heat stress were less likely to peak (OR 0.35 (95% CI 0.15 to 0.80), P=0.013), while sprint/power athletes reporting a sudden-onset injury complaint during the taper displayed increased peaking (OR 4.47 (95% CI 1.28 to 15.59), P=0.019). CONCLUSIONS: Health complaints that caused the athlete concern during the taper were predictive of failure to peak at a major athletics competition. Sprint/power athletes who experienced an acute injury symptom during the taper appeared to benefit from rest. Pre-cooling strategies seem to require further validation during real-world endurance/combined events. It appears that athletics athletes' self-reported health should be monitored during the taper, concerns addressed, and heat stress prevention strategies individually tested before championships in hot conditions.

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships.

BACKGROUND: Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type. DESIGN: Cross-sectional web-based survey. METHODS: A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination. RESULTS: A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation. CONCLUSIONS: The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

Perceptions of Overuse Injury Among Swedish Ultramarathon and Marathon Runners: Cross-Sectional Study Based on the Illness Perception Questionnaire Revised (IPQ-R).

BACKGROUND: Long-distance runners' understandings of overuse injuries are not well known which decreases the possibilities for prevention. The common sense model (CSM) outlines that runners' perceptions of a health problem can be described using the categories identity, consequence, timeline, personal control, and cause. The aim of this study was to use the CSM to investigate perceptions of overuse injury among long-distance runners with different exercise loads. METHODS: The study used a cross-sectional design. An adapted version of the illness perception questionnaire revised (IPQ-R) derived from the CSM was used to investigate Swedish ultramarathon and marathon runners' perceptions of overuse injuries. Cluster analysis was employed for categorizing runners into high and low exercise load categories. A Principal Component Analysis was thereafter used to group variables describing injury causes. Multiple logistic regression methods were finally applied using high exercise load as endpoint variable and CSM items representing perceptions of injury identity, consequence, timeline, personal control, and causes as explanatory variables. RESULTS: Complete data sets were collected from 165/443 (37.2%) runners. The symptoms most commonly associated with overuse injury were pain (80.1% of the runners), stiff muscles (54.1%), and stiff joints (42.0%). Overuse injury was perceived to be characterized by the possibility of personal control (stated by 78.7% of the runners), treatability (70.4%), and that the injury context was comprehensible (69.3%). The main injury causes highlighted were runner biomechanics (stated by 78.3%), the runner's personality (72.4%), and running surface biomechanics (70.0%). Among men, a belief in that personality contributes to overuse injury increased the likelihood of belonging to the high exercise load category [Odds ratio (OR) 2.10 (95% Confidence interval (95% CI) 1.38-3.19); P = 0.001], while beliefs in that running biomechanics [OR 0.56 (95% CI 0.37-0.85); P = 0.006) and mileage (OR 0.72 (95% CI 0.54-0.96); P = 0.026] causes injury decreased the likelihood. In women, a strong perception that overuse injuries can be controlled by medical interventions decreased the likelihood of high exercise load [OR 0.68 (95% CI 0.52-0.89); P = 0.005]. CONCLUSION: This study indicates that recognition among long-distance runners of the association between own decisions in overuse injury causation is accentuated by increased exercise loads.

Injury Pain in Track and Field Athletes: Cross-Sectional Study of Mediating Factors.

This exploratory study aimed to investigate whether data from track and field athletes support a conceptual model where the perception of pain affects self-evaluated health directly, yet is also indirectly mediated through personal factors and external stressors. A cross-sectional study was performed among athletes (n = 278) competing at the highest national level in the sport. Data for the dependent and independent variables were collected using the EuroQol-5 dimensions (EQ-5D) standardized measure of health status, and the mediator variables were collected by the Body Consciousness Scale (BCS-HA), Perceived Motivational Climate in Sport Questionnaire (PMCSQ), Commitment to Exercise Scale (CtES), and Brief Cope survey instruments. Two hundred and twenty-five (81%) athletes provided complete data sets. A strong direct association (c = -16.49; p < 0.001) was found between pain and self-estimated health, and a global mediation was found through the mediators (mediation effect (ME), -1.814, 90% confidence interval (CI), -3.414, -0.351). Specific mediation was observed for body competence (ME, -0.721; 90% CI, -2.028, -0.097) and private body consciousness (ME, -0.514; 90% CI, -1.761, -0.017). In conclusion, we found a negative association between perceived pain and self-evaluated health among competitive track and field athletes, and we found that a portion of the association was mediated through mediating factors. Under the assumption that the analyzed pain data primarily represented noxious pain, the conceptual model of the relationships between pain and self-estimated health among high-level track and field athletes was supported.

Lifetime history of sexual and physical abuse among competitive athletics (track and field) athletes: cross sectional study of associations with sports and non-sports injury.

OBJECTIVE: To examine associations between lifetime sexual and physical abuse, and the likelihood of injury within and outside sport in athletes involved in competitive athletics. METHODS: A cross sectional study was performed among the top 10 Swedish athletics athletes using 1 year prevalence of sports and non-sports injuries as the primary outcome measure. Associations with sociodemographic characteristics, lifetime abuse history and training load were investigated. Data were analysed using simple and multiple logistic regression models. RESULTS: 11% of 197 participating athletes reported lifetime sexual abuse; there was a higher proportion of women (16.2%) than men (4.3%) (P=0.005). 18% reported lifetime physical abuse; there was a higher proportion of men (22.8%) than women (14.3%) (P=0.050). For women, lifetime sexual abuse was associated with an increased likelihood of a non-sports injury (OR 8.78, CI 2.76 to 27.93; P<0.001). Among men, increased likelihood of a non-sports injury was associated with more frequent use of alcoholic beverages (OR 6.47, CI 1.49 to 28.07; P=0.013), while commencing athletics training at >13 years of age was associated with a lower likelihood of non-sports injury (OR 0.09, CI 0.01 to 0.81; P=0.032). Lifetime physical abuse was associated with a higher likelihood of sports injury in women (OR 12.37, CI 1.52 to 100.37; P=0.019). Among men, athletes with each parents with ≤12 years formal education had a lower likelihood of sustaining an injury during their sports practice (OR 0.37, CI 0.14 to 0.96; P=0.040). CONCLUSIONS: Lifetime sexual and physical abuse were associated with an increased likelihood of injury among female athletes. Emotional factors should be included in the comprehension of injuries sustained by athletes.

Preparticipation predictors for championship injury and illness: cohort study at the Beijing 2015 International Association of Athletics Federations World Championships.

OBJECTIVES: To determine preparticipation predictors of injury and illness at a major Athletics championship. METHODS: A cohort study design was used. Before the 2015 International Association of Athletics Federations World Championships in Athletics, all 207 registered national teams were approached about partaking in a study of preparticipation health; 50 teams accepted. The athletes (n=957) in the participating teams were invited to complete a preparticipation health questionnaire (PHQ). New injuries and illnesses that occurred at the championships were prospectively recorded. Logistic regression analyses were performed with simple and multiple models using any in-championship injury and in-championship illness as outcomes. RESULTS: The PHQ was completed by 307 (32.1%) of the invited athletes; 116 athletes (38.3%) reported an injury symptom during the month before the championships, while 40 athletes (13%) reported an illness symptom. 20 (6.5%) of the participating athletes sustained a health problem during the championships. Endurance athletes were almost 10-fold more likely to sustain an in-championship illness than speed/power athletes (OR, 9.88; 95% CI 1.20 to 81.31; p=0.033). Participants reporting a preparticipation gradual-onset injury symptom were three times more likely (OR, 3.09; 95% CI 1.08 to 8.79; p=0.035) and those reporting an illness symptom causing anxiety were fivefold more likely (OR, 5.56; 95% CI 1.34 to 23.15; p=0.018) to sustain an in-championship injury. SUMMARY AND CONCLUSIONS: Analyses of preparticipation predictors of injury and illness at a major Athletics championship suggest that endurance athletes require particular clinical attention. Preparticipation symptoms causing anxiety are interesting predictors for in-championship health problems.

Strategies and factors associated with preparing for competing in the heat: a cohort study at the 2015 IAAF World Athletics Championships.

PURPOSE: Assess exertional heat illness (EHI) history and preparedness in athletes competing in a World Athletics Championships under hot/humid conditions and identify the factors associated with preparedness strategies. METHODS: Of the 207 registered national teams invited to participate in the study, 50 (24%) accepted. The 957 athletes (49% of all 1965 registered) in these teams were invited to complete a precompetition questionnaire evaluating EHI history, heat stress prevention (heat acclimatisation, precooling and hydration) and recovery. Responses from 307 (32%) athletes were separated in field events, sprints, middle-distance and long-distance running, and decathlon/heptathlon for analysis. RESULTS: 48% of athletes had previously experienced EHI symptoms and 8.5% had been diagnosed with EHI. 15% heat acclimatised (∼20 days) before the championships. 52% had a precooling strategy, ice slurry ingestion (24%) being the most prevalent and women using it more frequently than men (p=0.005). 96% of athletes had a fluid consumption strategy, which differed between event categories (p<0.001). The most common volumes planned on being consumed were 0.5-1 L (27.2%) and ≥2 L (21.8%), water being the most frequent. 89% of athletes planned on using at least one recovery strategy. Female sex (p=0.024) and a previous EHI diagnosis increased the likelihood of using all 3 prevention strategies (p<0.001). CONCLUSIONS: At a World Championships with expected hot/humid conditions, less than one-fifth of athletes heat acclimatised, half had a precooling strategy and almost all a hydration plan. Women, and especially athletes with an EHI history, were more predisposed to use a complete heat stress prevention strategy. More information regarding heat acclimatisation should be provided to protect athlete health and optimise performance at major athletics competitions in the heat.

Perception of Health Problems Among Competitive Runners: A Qualitative Study of Cognitive Appraisals and Behavioral Responses.

BACKGROUND: Approximately 2 of every 3 competitive runners sustain at least 1 health problem each season. Most of these problems are nontraumatic injuries with gradual onset. The main known risk indicator for sustaining a new running-related injury episode is a history of a previous injury, suggesting that behavioral habits are part of the causal mechanisms. PURPOSE: Identification of elements associated with purposeful interpretations of body perceptions and balanced behavioral responses may supply vital information for prevention of health problems in runners. This study set out to explore competitive runners' cognitive appraisals of perceived symptoms on injury and illness and how these appraisals are transformed into behavior. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The study population consisted of Swedish middle- and long-distance runners from the national top 15 list. Qualitative research methods were used to categorize interview data and perform a thematic analysis. The categories resulting from the analysis were used to construct an explanatory model. RESULTS: Saturation of the thematic classification required that data from 8 male and 6 female runners (age range, 20-36 years) were collected. Symptoms interpreted to be caused by illness or injury with a sudden onset were found to lead to immediate action and changes to training and competition programs (activity pacing). In contrast, perceptions interpreted to be due to injuries with gradual onset led to varied behavioral reactions. These behavioral responses were planned with regard to short-term consequences and were characterized by indifference and neglect of long-term implications, consistent with an overactivity behavioral pattern. The latter pattern was consistent with a psychological adaptation to stimuli that is presented progressively to the athlete. CONCLUSION: Competitive runners appraise whether a health problem requires immediate withdrawal from training based on whether the problem is interpreted as an illness and/or has a sudden onset. The ensuing behaviors follow 2 distinct patterns that can be termed "activity pacing" and "overactivity."

The psychological factor 'self-blame' predicts overuse injury among top-level Swedish track and field athletes: a 12-month cohort study.

BACKGROUND: Athletes' psychological characteristics are important for understanding sports injury mechanisms. We examined the relevance of psychological factors in an integrated model of overuse injury risk in athletics/track and field. METHODS: Swedish track and field athletes (n=278) entering a 12-month injury surveillance in March 2009 were also invited to complete a psychological survey. Simple Cox proportional hazards models were compiled for single explanatory variables. We also tested multiple models for 3 explanatory variable groupings: an epidemiological model without psychological variables, a psychological model excluding epidemiological variables and an integrated (combined) model. RESULTS: The integrated multiple model included the maladaptive coping behaviour self-blame (p=0.007; HR 1.32; 95% CI 1.08 to 1.61), and an interaction between athlete category and injury history (p<0.001). Youth female (p=0.034; HR 0.51; 95% CI 0.27 to 0.95) and youth male (p=0.047; HR 0.49; 95% CI 0.24 to 0.99) athletes with no severe injury the previous year were at half the risk of sustaining a new injury compared with the reference group. A training load index entered the epidemiological multiple model, but not the integrated model. CONCLUSIONS: The coping behaviour self-blame replaced training load in an integrated explanatory model of overuse injury risk in athletes. What seemed to be more strongly related to the likelihood of overuse injury was not the athletics load per se, but, rather, the load applied in situations when the athlete's body was in need of rest.

Protocol design for large-scale cross-sectional studies of sexual abuse and associated factors in individual sports: feasibility study in Swedish athletics.

To ensure health and well-being for their athletes, sports organizations must offer preventive measures against sexual abuse. The aim of this study was to design and evaluate feasibility of a research protocol for cross-sectional epidemiological studies of sexual abuse in athletics. Examination of the requirements on the study of sexual abuse in athletics was followed by iterated drafting of protocol specifications and formative evaluations. The feasibility of the resulting protocol was evaluated in a national-level study among elite athletics athletes (n = 507) in Sweden. The definition of sexual abuse, the ethical soundness of the protocol, reference populations and study of co-morbidity, and the means for athlete-level data collection were identified as particularly complex issues in the requirements analyses. The web-based survey defined by the protocol facilitates anonymous athlete self-reporting of data on exposure to sexual abuse. 198 athletes (39%) fully completed the feasibility survey. 89% (n = 177) reported that they agreed with that the questions in the survey were important, and 95% (n = 189) reported that they answered truthfully to all questions. Similarly, 91% (n = 180) reported that they did not agree with that the questions were unpleasant for them. However, 16% (n = 32) reported that they did not find the survey to be of personal value, and 12% (n = 23) reported that the survey had caused them to think about issues that they did not want to think about. Responding that participation was not personally gratifying was associated with training more hours (p = 0.01). There is a scarcity of research on the prevention of sexual abuse in individual sports. The present protocol should be regarded as a means to overcome this shortcoming in athletics. When implementing the protocol, it is necessary to encourage athlete compliance and to adapt the web-based survey to the particular infrastructural conditions in the sports setting at hand. Key pointsA research protocol for cross-sectional epidemiological studies of sexual abuse in athletics was designed and its feasibility evaluated.The definition of sexual abuse, ethical soundness of the protocol, reference populations and study of co-morbidity, and means for athlete-level data collection were in requirements analyses identified as particularly complex design issues.The feasibility evaluation showed a high non-participation rate (61%), but also that the large majority of participants found the study important and that questions were answered truthfully.Responding that partaking in the study was not personally gratifying was associated with training more hours.When implementing cross-sectional epidemiological studies of sexual abuse in athletics, it is necessary to promote and facilitate athlete participation.

Meta-narrative analysis of sports injury reporting practices based on the Injury Definitions Concept Framework (IDCF): A review of consensus statements and epidemiological studies in athletics (track and field).

OBJECTIVES: Consistency in routines for reporting injury has been a focus of development efforts in sports epidemiology for a long time. To gain an improved understanding of current reporting practices, we applied the Injury Definitions Concept Framework (IDCF) in a review of injury reporting in a subset of the field. DESIGN: Meta-narrative review. METHODS: An analysis of injury definitions reported in consensus statements for different sports and studies of injury epidemiology in athletics (track and field) published in PubMed between 1980 and 2013 was performed. Separate narratives for each of the three reporting contexts in the IDCF were constructed from the data. RESULTS: Six consensus statements and 14 studies reporting on athletics injury epidemiology fulfilled the selection criteria. The narratives on sports performance, clinical examination, and athlete self-report contexts were evenly represented in the eligible studies. The sports performance and athlete self-report narratives covered both professional and community athletes as well as training and competition settings. In the clinical examination narrative, data collection by health service professionals was linked to studies of professional athletes at international championships. CONCLUSIONS: From an application of the IDCF in a review of injury reporting in sports epidemiology we observed a parallel usage of reporting contexts in this field of research. The co-existence of reporting methodologies does not necessarily reflect a problematic situation, but only provided that firm precautions are taken when comparing studies performed in the different contexts.